Name
*
First Name
Last Name
Email
*
example@example.com
Date
*
-
Month
-
Day
Year
Date
Respiratory Therapist Skills Checklist
Age / Population Experience
Rated on skill level 1-4: 1= no training, 2= class training, 3= Some experience, 4= Performs proficiently
New born (birth - 30 days)
*
1
2
3
4
Infant (age 30days -1 year
*
1
2
3
4
Toddler (age 1-3
*
1
2
3
4
Preschool (age 3-5)
*
1
2
3
4
School age (age 5-12)
*
1
2
3
4
Adolescent (age 12-18)
*
1
2
3
4
Young Adult (age 18-39)
*
1
2
3
4
Middle Adult (age 39-64)
*
1
2
3
4
Older Adult (age 64+)
*
1
2
3
4
General Skills:
Rated on skill level 1-4: 1= no training, 2= class training, 3= Some experience, 4= Performs proficiently
Standard Precautions
*
1
2
3
4
Isolation Precautions
*
1
2
3
4
Partial head to toe assessment
*
1
2
3
4
Infant/neonate cardiac/resp assessment
*
1
2
3
4
Adult cardiac/resp assessment
*
1
2
3
4
Prep and Admin of emergency meds
*
1
2
3
4
Crash cart use
*
1
2
3
4
Defibrillator
*
1
2
3
4
Care of patient in restraints
*
1
2
3
4
Medication dispensing system
*
1
2
3
4
Care of Patients With:
Rated on skill level 1-4: 1= no training, 2= class training, 3= Some experience, 4= Performs proficiently
ARDS
*
1
2
3
4
Acute / Chronic Bronchitis
*
1
2
3
4
Aspiration pneumonia
*
1
2
3
4
Status Asthmaticus
*
1
2
3
4
Bronchoscopy
*
1
2
3
4
Broncho-pulmonary displasia
*
1
2
3
4
CHF
*
1
2
3
4
Croup
*
1
2
3
4
Cystic Fibrosis
*
1
2
3
4
Epiglottis
*
1
2
3
4
Guillain Barre
*
1
2
3
4
Hemopneumothorax
*
1
2
3
4
Myasthenia Gravis
*
1
2
3
4
Pneumonia
*
1
2
3
4
Pulmonary Edema
*
1
2
3
4
Smoke Inhalation
*
1
2
3
4
TB
*
1
2
3
4
Tracheal-Esophageal Fistula
*
1
2
3
4
Tension Pneumo
*
1
2
3
4
Thoracotomy
*
1
2
3
4
Thoracotomay
*
1
2
3
4
Tracheal-Esophageal Fistula
*
1
2
3
4
Tracheotomy
*
1
2
3
4
Failure to Thrive
*
1
2
3
4
Fem Pop Bypass
*
1
2
3
4
Laryngospasm
*
1
2
3
4
Meconium Aspiration
*
1
2
3
4
Near Drowning
*
1
2
3
4
Persistent Pulmonary HTN
*
1
2
3
4
Pulmonary interstitial Emphysema
*
1
2
3
4
RSV
*
1
2
3
4
Transient Tachypnea of newborn
*
1
2
3
4
Medicine Administration:
Rated on skill level 1-4: 1= no training, 2= class training, 3= Some experience, 4= Performs proficiently
Atrovent
*
1
2
3
4
Albuterol
*
1
2
3
4
Bicarb
*
1
2
3
4
Breo
*
1
2
3
4
Combivent
*
1
2
3
4
Incruse
*
1
2
3
4
Isuprel
*
1
2
3
4
Mucomyst
*
1
2
3
4
Pulmicort
*
1
2
3
4
Racemic Epi
*
1
2
3
4
Spiriva
*
1
2
3
4
Terbutaline Sulfate
*
1
2
3
4
Theophylline
*
1
2
3
4
Xopenex
*
1
2
3
4
Knowledge of Effects:
Rated on skill level 1-4: 1= no training, 2= class training, 3= Some experience, 4= Performs proficiently
Alupent
*
1
2
3
4
Anectine
*
1
2
3
4
Atropine
*
1
2
3
4
Azmacort
*
1
2
3
4
Bronkosol
*
1
2
3
4
Corticosteroids
*
1
2
3
4
Cromolyn Sodium
*
1
2
3
4
Decadron
*
1
2
3
4
Diazepam
*
1
2
3
4
Digoxin
*
1
2
3
4
Dopamine
*
1
2
3
4
FLovent
*
1
2
3
4
Inhaled Steroids
*
1
2
3
4
Ketamine
*
1
2
3
4
Lasix
*
1
2
3
4
Lidocaine
*
1
2
3
4
Morphine
*
1
2
3
4
Nitric Oxide
*
1
2
3
4
Pavulon
*
1
2
3
4
Propofol
*
1
2
3
4
Tobramycin
*
1
2
3
4
Versed
*
1
2
3
4
Ventilators / Equipment:
Rated on skill level 1-4: 1= no training, 2= class training, 3= Some experience, 4= Performs proficiently
Achieva
*
1
2
3
4
Siemens
*
1
2
3
4
Bi-Pap
*
1
2
3
4
PB7200
*
1
2
3
4
Sechrist IV 100B
*
1
2
3
4
Servo V60
*
1
2
3
4
Assist Control
*
1
2
3
4
CPAP
*
1
2
3
4
Flow- By
*
1
2
3
4
High Frequency Ventilator
*
1
2
3
4
IMV
*
1
2
3
4
Inverse Ratio Vent
*
1
2
3
4
Pressure Support
*
1
2
3
4
Pressure Vents
*
1
2
3
4
SIMV
*
1
2
3
4
Troubleshooting High and Low alarms
*
1
2
3
4
O2 / Air delivery systems:
Rated on skill level 1-4: 1= no training, 2= class training, 3= Some experience, 4= Performs proficiently
Ambu Bag
*
1
2
3
4
Croup Tent
*
1
2
3
4
E-Cylinders
*
1
2
3
4
Nasal Cannula
*
1
2
3
4
Non-Rebreather
*
1
2
3
4
T-Piece
*
1
2
3
4
Trach Collar
*
1
2
3
4
Venti Mask
*
1
2
3
4
ABG - List
*
1
2
3
4
Nebulizers:
Rated on skill level 1-4: 1= no training, 2= class training, 3= Some experience, 4= Performs proficiently
Hand Held
*
1
2
3
4
Humidification
*
1
2
3
4
Ultrasonic Nebulizers
*
1
2
3
4
MDI (Meter Dose Inhaler):
Rated on skill level 1-4: 1= no training, 2= class training, 3= Some experience, 4= Performs proficiently
Aero Chamber
*
1
2
3
4
IPPB (Intermittent Positive Pressure)
*
1
2
3
4
Procedures:
Rated on skill level 1-4: 1= no training, 2= class training, 3= Some experience, 4= Performs proficiently
Postural Drainage
*
1
2
3
4
Chest Percussion
*
1
2
3
4
ABG
*
1
2
3
4
Allen Test
*
1
2
3
4
Femoral
*
1
2
3
4
Arterial
*
1
2
3
4
Set up and calibrate arterial Line
*
1
2
3
4
Analyze ABG results
*
1
2
3
4
Interpret ABG results
*
1
2
3
4
Airway Management:
Rated on skill level 1-4: 1= no training, 2= class training, 3= Some experience, 4= Performs proficiently
Tracheal Suction
*
1
2
3
4
Endotracheal Suction
*
1
2
3
4
Nasotracheal Suction
*
1
2
3
4
Oral Suction
*
1
2
3
4
In-Line Suction
*
1
2
3
4
Checking Cuff Pressure
*
1
2
3
4
Extubation
*
1
2
3
4
Intubation
*
1
2
3
4
Signature
*
Submit
Should be Empty: